Seizure Plan of Care. Seizure History. Contact Information. Other Emergency Contacts:

Transcription

1 Form to be completed by Parents/Guardians and Child s Health Care Provider. School Year Student s Grade Mother/Guardian Homeroom Teacher Contact Information Date of Birth Father/Guardian Student s Doctor/Health Care Provider: Address Telephone Emergency Number Other Emergency Contacts: Relationship Relationship Please remember to let your child s school know of any changes to the contact information as soon as possible. Notify parent in the following situations: Seizure History Seizure Type (please check all that apply) Generalized: Tonic Clonic (grand mal) Atonic (drop attacks) Myoclonic Absence (petit mal) Partial: Simple Complex (psychomotor/temporal lobe) Other or Description of seizure How often do seizures occur: How long does a typical seizure last: Date of last seizure: Warning signs (aura) or triggers if any, please explain:

2 List known triggers for your child s seizures Age when seizures were diagnosed: Date of last exam for this condition: Student s reaction to seizure Yes No Does student need to leave the classroom after a seizure? If yes, describe process for returning to classroom Yes No Notify parent/guardian immediately for all seizure activity Other instructions: Any special considerations or safety precautions: TO BE COMPLETED BY PHYSICIAN OR LICENSED PRESCRIBER Medication(s) given at home: Medications Medication Allergies: Yes No Are any medications to be given during the school day? Medication(s) to be administered during school hours by school personnel for control of seizures: Prescription: Medication: Dosage, Time, Route: Duration: Date of Prescription: Possible Side effects: Medication: Dosage, Time, Route: Duration: Date of Prescription: Possible Side effects:

3

4 If seizure activity occurs, provide the following measures: Clear area of on lookers Ease student to floor DO NOT restrain or attempt to hold down Remove hazards in the area, such as sharp or hard objects (Desks, chairs, books, etc) Turn the student onto his/her side to maintain airway after a seizure DO NOT attempt to place any foreign object in mouth Have designated person contact Health Aide and/or parent/guardian Document seizure activity: Date, time, length of seizure Rest, re-orient, and offer assurance following seizure Other: Administer Diastat rectal gel for seizure lasting longer than Other instructions for Diastat : No Diastat ordered minutes. Dose Call 911 for ANY of the following: (Please check all that apply) Seizure lasts more than minutes. Anytime Diastat is given Only if seizure does not stop within minutes after giving Diastat Two or more consecutive seizures occur Student is injured or has diabetes Student has difficulty breathing Other: I give permission to the school health aide or other designated staff members of School to perform and carry out this Seizure Plan of Care established by our physician and myself. I also consent to the release of information contained in this medical management plan to all staff members and other adults who have custodial care of my child and who may need to know this information to maintain my child s health and safety. I give consent for school personnel to exchange information with my child s physician for the benefit of his/her health care. Parent/Guardian Signature: Date: Physician/Prescriber Signature: Date: Physician/Prescriber PRINTED name: Phone Number: Fax Number:

5 Seizure Type Descriptions Simple Partial Remains conscious, twitching or numb sensation, usually lasting less than 30 seconds. Complex Partial Altered consciousness, transient staring, feelings of unreality and detachment. May have hallucinations, unexplained feelings of fear, disrupted memory, teething grinding, lip smacking, chewing, swallowing, scratching or pulling at buttons. Lasts usually no longer than 1-2 minutes. Tonic-Clonic Abrupt arrest of activity, loss of consciousness, symmetrical and rhythmical alterations of contraction and relaxation of major muscle groups. Ends suddenly in less than 5 minutes Atonic Abrupt loss of postural tone, loss of consciousness, confusion, lethargy and sleep. (May just fall asleep suddenly; when laughing, the child may fall down.) Myoclonic Brief random contractions of a muscle group, may occur on one side of the body, no loss of consciousness. Absence Very brief periods of altered awareness, eyelids may flutter or twitch, blank facial expression, lasts 5-10 seconds but can occur repeatedly. Tonic Lack of movement, stiffening of the entire body musculature, arms flex, legs, neck and head extend. Peculiar, piercing cry, cyanosis (bluish coloring to skin), may temporarily stop breathing, increased salivation. Akinetic No movement, but muscle tone is maintained. Like "freezing into position," may lose consciousness.